Educating Physicians

EDUCATING PHYSICIANS The current blueprint for medical education in North America was drawn up in 1910 by Abraham Flexner in his report Medical Education in the United States and Canada. The basic features outlined by Flexner remain in place today. Yet with the past century's enormous societal changes, the practice of medicine and its scientific, pharmacological, and technological foundations have been transformed. Now medical education in the United States is at a crossroads: those who teach medical students and residents must choose whether to continue in the direction established over a hundred years ago or to take a fundamentally different course, guided by contemporary innovation and new understandings about how people learn. Emerging from an extensive study of physician education by The Carnegie Foundation for the Advancement of Teaching, Educating Physicians calls for a major overhaul of the present approach to preparing doctors for their careers. The text addresses major issues for the future of the field and takes a comprehensive look at the most pressing concerns in physician education today. The key findings of the study recommend four goals for medical education: standardization of learning outcomes and individualization of the learning process; integration of formal knowledge and clinical experience; development of habits of inquiry and innovation; and focus on professional identity formation. Like The Carnegie Foundation's revolutionizing Flexner Report of 1910, Educating Physicians is destined to change the way administrators and faculty in medical schools and programs prepare their physicians for the future.

PRAISE FOR EDUCATING PHYSICIANS "Educating Physicians provides a masterful analysis of undergraduate and graduate medical education in the United States today. It represents a major educational document, based firmly on educational psychology, learning theory, empirical studies, and careful personal observations of many individual programs. It also recognizes the importance of financing, regulation, and institutional culture on the learning environment, which suffuses its recommendations for reform with cogency and power. Most important, like Abraham Flexner's classic study a century ago, the report recognizes that medical education and practice, at their core, are profoundly moral enterprises. This is a landmark volume that merits attention from anyone even peripherally involved with medical education." —Kenneth M. Ludmerer, author, Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care "This is a very important book that comes at a critical time in our nation's history. We will not have enduring health care reform in this country unless we rethink our medical education paradigms. This book is a call to arms for doing just that." —George E. Thibault, president, Josiah Macy, Jr. Foundation "The authors provide us with the evidence-based model for physician education with associated changes in infrastructure, policy, and our roles as educators. Whether you agree or not with their conclusions, if you are a teacher this book is a must-read as it will frame both what and how we discuss medical education throughout the current century." —Deborah Simpson, associate dean for educational support and evaluation, Medical College of Wisconsin "A provocative book that provides us with a creative vision for medical education. Using in-depth case studies of innovative educational practices illustrating what is actually possible, the authors provide sage advice for transforming medical education on the basis of learning theories and educational research." —Judith L. Bowen, professor of medicine, Oregon Health & Science University

Recent surveys of medical students reveal stark conditions: more than a quarter have experienced episodes of depression during their medical school and residency careers, a figure much higher than that of the general population. Compounded by long hours of intellectually challenging, physically taxing, and emotionally exhausting work, medical school has been called one of the most harrowing experiences a student can encounter. Plumbing the diaries, memoirs, and blogs of physicians-in-training, Suzanne Poirier's Doctors in the Making illuminates not just the process by which students become doctors but also the physical, emotional, and spiritual consequences of the process. Through close readings of these accounts, Poirier draws attention to the complex nature of power in medicine, the rewards and hazards of professional and interpersonal relationships in all aspects of physicians' lives, and the benefits to and threats from the vulnerability that medical students and residents experience. Although most students emerge from medical education as well-trained, well-prepared professionals, few of them will claim that they survived the process unscathed. The authors of these accounts document--for better or for worse--the ways in which they have been changed. Based on their stories, Poirier recommends that medical education should make room for the central importance of personal relationships, the profound sense of isolation and powerlessness that can threaten the wellbeing of patients and physicians alike, and the physical and moral vulnerability that are part of every physician's life.

At a time when medical care for the people of the United States is undergoing wrenching change due mainly to vast and costly technological progress, doctors have had to cede much of their initiative and responsibility to third parties. Medicine has become a commercial enterprise. Patients must affiliate themselves with a managed health care organization in order to have access to their doctors. In the hurly-burly of today's techno-medicine, many physicians are too busy to spend time in dialogue with their patients. As a consequence, social and emotional circumstances that have been thoroughly documented to affect physiology and susceptibility to disease are overlooked. Stewart Wolf here critiques the medical establishment and the way those concerned with its various responsibilities discharge them. He puts medicine's responsibilities to society into historical perspective, relating it to social changes. He begins with the ways medical candidates are selected. He continues with commentary on currently designed teaching and learning, the qualities required in a physician and in a medical scientist, and the nature and challenges of disease and what can be done about them. Finally, Wolf provides a useful way of thinking about human biology, to better understand why people become sick or well and what people have to contend with to stay well. Throughout he emphasizes the role of the brain in controlling behavior of all sorts, general and visceral. Wolf emphasizes the regulatory power of the nervous system as it perceives and evaluates life experiences and influences learning, behavior, and susceptibility to disease. Wolf'sgoal is not to supply a recipe for the achievement of better health, but to encourage a better understanding of ourselves and the paths toward health. Educating Doctors reexamines the responsibilities, goals, and activities of the medical establishment. As such it is a must read for policymakers, sociologists, and professionals working in the medical field.

Focusing on the social, intellectual, and political context in which medical education took place, Thomas Neville Bonner offers a detailed analysis of transformations in medical instruction in the United Kingdom, France, Germany, and the United States between the Enlightenment and World War II. From a unique comparative perspective, this study considers how divergent approaches to medical instruction in these countries mirrored as well as impacted their particular cultural contexts. The book opens with an examination of key developments in medical education during the late eighteenth century and continues by tracing the evolution of clinical teaching practices in the early 1800s. It then charts the rise of laboratory-based teaching in the nineteenth century and the progression toward the establishment of university standards for medical education during the early twentieth century. Throughout, the author identifies changes in medical student populations and student life, including the opportunities available for women and minorities.

The renewal of medical curricula generally arises from emerging pedagogies (e.g. problem-based learning), new technologies (e.g. high fidelity simulation), or prevailing sociocultural forces (e.g. complexity of health care delivery and team-based care). Approximately 15 years ago, a team of physicians and administrators sought to take this further: by considering the very nature of medical practice and the patient-physician relationship that is the context and conduit of caring and care, they restructured the composition and function of medical education. This book, Physicianship and the Rebirth of Medical Education, is the authoritative publication on the philosophy, design, and implementation of this new curriculum. From first year to graduation, this book reimagines the education of medical students in its entire scope. It discusses the epistemology of clinical practice and pedagogical methods and addresses pragmatic issues of curricular implementation. The educational blueprint presented in the book rests on a new definition of sickness, one focused on impairments of function as the primary issue of concern for both patients and their care givers. This perspective avoids the common shift of medical attention from persons to diseases, and thus provides the basis for an authentic and robust patient-centered mindset. The title of the book refers to a "rebirth." This implies that there was a previous "birth." Indeed, the critical ingredients of medical education were articulated historically and many features emanate from a time-honored apprenticeship model. This book recognizes in William Osler and his "natural method of teaching the subject of medicine" the foundational elements for teaching physicianship. The practice of medicine is indelibly relational and, in turn, medical education is an intellectual and an emotional journey that is rooted in clinical relationships. As this book shows, medicine must unfold in the context of patient care; patients, not diseases, should be the center of attention.